Vulvovaginal candidiasis (VVC) is one of the most common conditions affecting women. VVC is an inflammatory condition caused by Candida spp. Hypothesized risk factors include pregnancy, diabetes mellitus, contraceptive method, antibiotics, tight fitting clothing, sexual practices, feminine hygiene and diet. According to the Centers for Disease Control and Prevention (CDC), an estimated 75% of women will have at least one episode of VVC, and 40% to 45% will have two or more episodes in their lifetime (CDC Treatment Guidelines, Vulvovaginal Candidiasis, 2002). In addition, approximately 10-20% of women suffer from Complicated VVC, which is characterized by 1) infections which may be due to non-albicans species of Candida; 2) occur on a recurrent basis (>4 episodes/12 months); or 3) are more severe than Uncomplicated VVC (CDC Treatment Guidelines, supra; Sobel J., 1999, Drug Resist Update, 2:148-152). While some percentage of chronic recurring VVC may be explained by genetic predisposition, little is known about risk factors for acquiring a first or second episode.
Despite newer therapeutic agents, attempts at better compliance (such as tablet formulations and short-term treatments) and adoption of suppressive maintenance therapies, the effective management of complicated VVC remains problematic. Currently available antifungals, available by either prescription or over the counter (OTC), are indicated for the treatment of Uncomplicated acute VVC (characterized by sporadic, infrequent attacks of mild-to-moderate severity due to C. albicans; CDC Treatment Guidelines, supra; Sobel 1999, supra). However, the use of these products in women with Complicated VVC has proven to be unsuccessful.
Attempts to increase therapeutic efficacy in women with Complicated VVC have entailed the use of maintenance suppressive azole regimens. Examples of azole antifungal agents include fluconazole, butoconizole, itraconazole, clotrimazole, econazole, miconazole, oxiconazole, terconazole, tioconazole, and ketoconazole. Long-term studies in women with recurrent disease indicate that at least half of the patients who remain in clinical and mycological remission while on maintenance therapy will rapidly relapse following cessation of therapy (Sobel J. et al, 2004; N. Engl. J. Med., 351:876-883; Balkis M. et al, 2002, Drugs, 62:1025-1040; Fidel P. et al, 1996, Clin. Microbiol. Rev., 9:335-348; Sobel J. et al, 1998, Mycoses, 41 Suppl. 2:18-22). A substantial amount of evidence exists confirming this high rate of clinical failure to control disease in women with Complicated VVC treated with these currently available antifungal products (Sobel, J. 2004, supra; Balkis, M. 2002, supra; Fidel, P. 1996, supra; Sobel, J. 1998, supra; MacNeill C. et al, 2001, Curr. Womens Health Rep. 1:31-35; Berg A et al, 1984, J. Amer. Med. Assn., 251:620-625; McCormack W. et al, 1994, Sex Transm. Dis., 21:63-64.) Treatment of Uncomplicated VVC with non-azole antifungals, such as the polyene antimicrobials nystatin and amphotericin B (AmB) has been somewhat successful. However, severe issues relating to the ability of the fungal pathogens to acquire resistance to currently-used medication is an escalating problem.
The widespread reports of fluconazole resistance in Candida species has prompted the study of species distribution of vulvovaginal candidiasis and their in vitro susceptibility against current antifungal agents. A total of 314 women with vaginal infection were studied. Yeasts were isolated from 104 patients with vulvovaginal candidiasis. The following species were identified: C. albicans 87.5%, C. glabrata 8.6% and 3.9% included C. krusei, C. famata, and C. tropicalis. The minimal inhibitory concentration (MIC) was determined for nystatin, isoconazole, fluconazole and ketoconazole, using a broth micro dilution method based on National Committee on Clinical Laboratory Standards (NCCLS) procedure. Although most of the isolates were C. albicans, the high percentage of C. glabrata recovered suggests the need to identify the yeasts isolated. Fluconazole resistant C. albicans were isolated in 13.46% of the cases. (Saporiti, A. et al, 2001, Rev. Argent. Microbiol.; 33(4):217-22).
Other workers isolated and identified the yeast species in the vagina of patients treated in the gynecology clinic and tested in vitro activities of fluconazole and itraconazole against 227 clinical yeast isolates by the NCCLS micro dilution method. C. albicans (87.6%) was the most frequently identified species followed by C. glabrata (6.2%) and C. krusei (2.2%). Almost thirteen percent of yeast strains were resistant to fluconazole and 18.5% were resistant to itraconazole. Cross-resistance analyses of C. albicans isolates revealed that fluconazole resistance and itraconazole resistance were also associated with decreased susceptibilities to other azole derivatives mainly to ketoconazole and miconazole. At the same time no cross-resistance to polyene antibiotics amphotericin B and nystatin was observed. These results support the notion that antifungal agents used to treat vaginitis may be contributing to the drug resistance problem by promoting cross-resistance to a range of clinically used antifungals. (Sojakova, M. et al, 2004, Mycopathologia, February;157(2):163-9).
In another study, the in vitro susceptibility to amphotericin B, fluconazole, itraconazole and ketoconazole of 545 Candida strains from patients treated at the University Hospital of the Canaries was determined by means of a micro dilution test. The distribution of the species was as follows: Candida albicans (342), Candida tropicalis (70), Candida glabrata (68), Candida parapsilosis (65). Of Candida albicans isolates, 8.5% and 7.6% showed resistance to itraconazole and fluconazole respectively. Of C. tropicalis isolates 34.3%, 27.1% and 2.9% were resistant to itraconazole, fluconazole and ketoconazole respectively. For C. glabrata, 10.3% and 4.4% of the isolates under study demonstrated resistance to fluconazole and itraconazole respectively. Only 4.6% and 1.5% of C. parapsilosis isolates demonstrated resistance to fluconazole and itraconazole respectively. C. tropicalis was the most resistant strain and C. parapsilosis the most sensitive. The greatest percentages of resistance in vitro were seen with the triazoles (Arias, A. et al, 1994, Mycoses; 37(7-8):285-9.)
In attempts to find antifungal agents which are capable of treating candidiasis without imparting serious side-effects or drug resistance, clinicians have investigated topical applications of the powerful antifungal flucytosine (5-fluorocytosine, 5-FC, or 4-amino-5-fluoropyrimidin-2(1H)-one) to patients with candidiasis refractory to treatment with either azole antifungals or AmB.
Flucytosine, marketed in the U.S. as the oral formulation ANCOBON® only for treatment of serious systemic infections of Candida and Cryptococcus, has the potential to cause serious side effects when taken orally. The ANCOBON® package insert (Physicians Desk Reference 2001, 55:1530) contains explicit warnings concerning the systemic use of the drug. ANCOBON® must be given with extreme caution to patients with impaired renal function. Since ANCOBON® is excreted primarily by the kidneys, renal impairment may lead to accumulation of the drug. ANCOBON® serum concentrations should be monitored to determine the adequacy of renal excretion in such patients. Dosage adjustments should be made in patients with renal insufficiency to prevent progressive accumulation of active drug. ANCOBON® must be given with extreme caution to patients with bone marrow depression. Patients may be more prone to depression of bone marrow function if they: 1) have a hematologic disease, 2) are being treated with radiation or drugs which depress bone marrow, or 3) have a history of treatment with such drugs or radiation. Bone marrow toxicity can be irreversible and may lead to death in immunosuppressed patients. Frequent monitoring of hepatic function and of the hematopoietic system is indicated during therapy. Among side effect and adverse reactions to systemic flucytosine are the following: cardiac arrest, myocardial toxicity, respiratory arrest, chest pain, dyspnea, rash, pruritus, urticaria, photosensitivity, nausea, emesis, abdominal pain, diarrhea, anorexia, dry mouth, duodenal ulcer, gastrointestinal hemorrhage, acute hepatic injury with possible fatal outcome in debilitated patients, hepatic dysfunction, jaundice, ulcerative colitis, bilirubin elevation, increased hepatic enzymes, azotemia, creatinine and BUN elevation, crystalluria, renal failure, anemia, agranulocytosis, aplastic anemia, eosinophilia, leukopenia, pancytopenia, thrombocytopenia, ataxia, hearing loss, headache, paresthesia, parkinsonism, peripheral neuropathy, pyrexia, vertigo, sedation, convulsions, confusion, hallucinations, psychosis, fatigue, hypoglycemia, hypokalemia, weakness, allergic reactions, and Lyell's syndrome. Thus, in the administration of flucytosine for the treatment of fungal infection, there is a concern that improper systemic levels of the drug could lead to deleterious side effects. It has been demonstrated, for example, that plasma levels of greater than 100 mg/L in human patients has led to bone marrow depression (leucocytopenia, thrombocytopenia, and pancytopenia) and hepatotoxicity (Kauffmann, C. et al 1977; Antimicrob. Agents Chemother. 11:244-247).
There are also concerns that systemic use of flucytosine might give rise to flucytosine-resistant pathogens. Previous studies have indicated that flucytosine should be avoided in antimicrobial therapy. Previous workers warn that flucytosine usage is limited due to the development of resistance to the drug and due to its narrow spectrum of activity (Alexis, B. et al, U.S. Pat. No. 6,818,231). Others state that flucytosine has limited clinical utility, as clinical isolates of Candida develop resistance to flucytosine, and consequently, antibiotic therapy for candidiasis is highly variable from one individual to the next and resolution of fungal lesions is primarily associated with improved immunocompetence, as opposed to direct antifungal therapy (O'Donnell, U.S. Pat. No. 5,455,028). It is reported that flucytosine resistance is common, especially when used as monotherapy for candida, and that adverse effects are displayed as well (Aerts et al, US Pat. Appl. Publ. 20040253224). One report cautions that flucytosine is indicated only for serious microbial infections, and that mitigation of the usefulness of this powerful drug is to be avoided by sparing use. (Normark, S. et al, 1972, Antimicrob. Agents Chemother.; 2:114).
It has been shown that sensitization to flucytosine depends upon the oral dose and duration of treatment (Hope, W. et al, 2006; Antimicrob. Agents Chemother., 50:3680). Also, it is known that up to 30% of patients who receive oral flucytosine therapy develop resistance to the drug (Perea, S. et al, 2002; Clin. Infect. Dis., 35:1073-1080). Indeed, the use of flucytosine oral therapy has been restricted by the high prevalence of resistance and by the speed at which oral flucytosine therapy develops resistant organisms after treatment (Sangland, D. et al, 2002; Lancet Infectious Diseases, 2:73-85).
The topical administration of flucytosine has been shown in isolated studies to be an effective treatment for candidiasis. An early study assessed the efficacy of flucytosine topically applied to intertriginous candidiasis (disease between folds or juxtaposed surfaces of the skin). A formulation containing 10% flucytosine was compounded using Ancotil (a 10 g/l flucytosine for infusion solution available in the U.K.) into a cream base. The composition of the formulation was not disclosed. Clinicians found that the compounded flucytosine and nystatin gel were equally effective at treating the infection, and that no side effects were observed. No attempts were reported to assess or control the transdermal or transmucosal delivery of flucytosine to the blood. (Gisslen, H. et al, 1974, Dermatologia, 148:362-365.)
Since the only approved dosage form of flucytosine currently available in the U.S. is ANCOBON® formulated in an oral capsule, clinicians have resorted to crushing capsule contents, and mixing the resultant powder into a suitable cream base in order to incorporate flucytosine into a formulation suitable for topical administration to VCC patients.
A method for preparing a flucytosine formulation for topical application to the vagina has been described (Horowitz B., 1986; J. Reprod. Med. 31:821-824). A study was performed which evaluated topical flucytosine therapy for chronic recurrent Candida tropicalis infections. In this study, patients identified as having C. tropicalis vaginitis were begun on topical miconazole nitrate 2% or topical clotrimazole cream 1%, one application nightly for seven nights. If this therapy failed, ketoconazole, 200-mg/d for 14 days, was begun. Following this, those patients who continued to have symptoms and to culture C. tropicalis were given an intravaginal dose of flucytosine cream. The dose of 1 g daily was chosen based upon the oral dosing of 2.5 g to 7.5 g a day (ANCOBON® Labeling).
ANCOBON®, 1 g per applicator, was compounded into a cold cream base. Flucytosine cream was created by opening fourteen 500-mg capsules of ANCOBON® into a mortar and reducing this to a fine powder. The powder was levigated with glycerin to form a smooth paste. The levigated mixture was added to hydrophilic ointment base or cold cream, q.s., to 45 g. This mixture was blended until smooth, and two 2 ounce ointment tubes were filled. The patient was instructed to insert the mixture into a 6.4 g vaginal applicator and dispense the cream vaginally.
A total of 936 patients were involved in the study. Of the 962 cultures prepared, 267 were positive for C. albicans and 25% for C. tropicalis. Forty-one patients yielded 68 cultures positive for C. tropicalis. Twenty-eight patients were initially treated with 2% miconazole nitrate, one application each night for seven nights. Thirteen patients were treated for seven nights with one application nightly of 1% clotrimazole cream.
Twelve patients treated with 2% miconazole nitrate cream had recurrences, and three treated with clotrimazole cream had recurrences. Two miconazole nitrate patients and 1 clotrimazole patient were treated secondarily with ketoconazole, 200-mg, for 14 days. In all three of these patients, the infection recurred.
After treatment 15 uncured patients remained. All 15 patients with recurring candidiasis were then treated with compounded flucytosine vaginal cream. Patients applied 5 g of flucytosine cream (approximately 1 g flucytosine) vaginally every night for 14 nights. This treatment resulted in clinical cure in 14 patients. The 15th patient remained uncured, but she reported that her recurrences were less frequent. The cream was well tolerated (no reported symptoms of irritation, inflammation and burning). In this study, no attempts were reported to assess or control the transdermal or transmucosal delivery of flucytosine to the blood.
A very limited study (n=3) was conducted in which AmB and flucytosine were compounded together in lubricating jelly, and this mixture of antifungals was applied topically to women suffering from azole-resistant infection of C. glabrata. The clinicians reported a formulation of 12.5% flucytosine and 1.25% AmB in lubricating gel, applied topically, was effective in treating the disease (White, D. et al, 2001, Sex. Trasm. Inf., 77:212-213.) No attempts were reported to assess or control the transdermal or transmucosal delivery of flucytosine to the blood.
In a retrospective review, case records of 141 women with positive vaginal cultures of C. glabrata were inspected to evaluate the treatment outcome and safety of therapy with boric acid or flucytosine vaginal cream. The review demonstrated that a boric acid regimen of 600-mg day for 2 to 3 weeks achieved clinical and mycological success in 47 of 73 symptomatic women (64%). No advantage was observed in extending therapy for 14 to 21 days. Intravaginal flucytosine cream was offered to 30 patients, 26 of whom had previously received boric acid therapy, with either short-term failure or relapse. The flucytosine cream was prepared as described by Horowitz (1986, supra.) Patients applied 5 g of flucytosine vaginal cream (equivalent to 1 g flucytosine) vaginally every night for 14 nights. Intravaginal flucytosine cream administered nightly for 14 days was associated with a successful outcome in 27 of 30 women (90%). One patient was lost to follow-up. The remaining 2 patients were treated with oral itraconazole and intravaginal nystatin resulting in a cure in one patient. All patients completed and tolerated vaginal flucytosine therapy (Sobel J., 2003; Am. J. Obstet. Gynecol. 189:1297-1300). In this study, no attempts were reported to assess or control the transdermal or transmucosal delivery of flucytosine to the blood.
Thus, these limited prior studies provide conflicting suggestions that although topically applied anti-mycotics including flucytosine can potentially be effective in the treatment of fungal infections, flucytosine use should be avoided due to its propensity for the formation of drug-resistant fungal strains and deleterious side effects. Furthermore, previous efforts have failed to provide an effective, simple, cost-effective, easy to administer, highly patient-compliant, safe, and effective means to treat serious fungal disease. Specifically, there is an outstanding unmet need for highly effective agents for treating VVC and other fungal infections, but which present limited potential for side effects and adverse reactions. More specifically, there is an outstanding unmet need for agents to treat VCC and other fungal diseases which have a high degree of clinical effectiveness against strains of Candida spp. which have developed resistance to commonly used and commonly available antifungal drugs. The present invention discloses embodiments which provides solutions to these problems.